Hospital discharge planning is a frequently occurring and expensive hospital care process done annually for more than 13 million Medicare beneficiaries. The process has multiple steps that require careful, comprehensive assessment to adequately determine patients' present needs, anticipate future needs, make appropriate referral decisions, and coordinate follow-up services. Although the volume of decisions for hospitalized older adults is high, there are no nationally recognized, empirically derived decision support tools in use to assist discharge planners and others in making these important decisions. The completed National Institute of Nursing Research study (RO1- NR07674), and further development and testing, resulted in the patent pending invention called the Discharge Decision Support System (D2S2) 2,3 This invention is poised for commercialization by our company, RightCare Solutions. Based on a prediction model of patient symptoms and other characteristics, and referral decisions made by experts, the D2S2 is a valid and reliable decision tool that identifies which hospitalized patients should be considered for referral for post-acute care (PAC) such as home care or skilled nursing facility.3 The quality of these decisions determines whether older adults receive the PAC services they need, to return, and remain successfully in their homes. The proposed study purpose is to increase the commercial application of the D2S2 by increasing the speed of delivery, sophistication, and dissemination of the decision support through automation. A second aim will evaluate the implementation and impact on readmissions. The study involves technology development to assist clinicians in timely use and delivery of the D2S2 advice. These enhancements will guide clinicians to anticipate and better match services to patients' needs more quickly and accurately. Completion of these aims will result in successful production of a marketable, technologically innovative, and highly effective decision support tool that directs patients to the right care. PUBLIC HEALTH RELEVANCE: This decision support software will enhance the referral decision making of hospital clinicians as they prepare patients for hospital discharge. Development of this product will improve identification of patients who would benefit from care after hospital discharge by providing expert advice and additional information about patients. Patients who have their needs met are more likely to have good outcomes.